Newsletter

A NOTE FROM DR. THREATT Men with irritative as well as obstructive symptoms
should be evaluated for incomplete emptying. Use caution when prescribing anticholinergics (Detrol, This is volume 2 of our newsletter; the focus will be Vesicare, Enablix, etc.) as these medications can result on benign prostatic hypertrophy (BPH). This issue will in urinary retention. Checking a urine flow rate and a provide you with current information on the evaluation post void residual is usually adequate. In diabetics and and treatment of BPH from watchful waiting to surgical patients with neurogenic bladders (stroke, spinal cord injury) urodynamics are usually helpful in directing EDUCATION CORNER
management. Below is a helpful algorithm to use when managing Lower urinary tract symptoms (LUTS)/BPH include, patients with BPH.
frequency, urgency, hesitancy, nocturia, incomplete emptying, weak urine stream, and post void dribbling. These symptoms occur in 25% of men older than 40 years of age and 33% of men older than 65 years of age.
BPH is a progressive condition. Men 60 to 69 years of age with moderate LUTS have a 13% 10 year cumulative risk of urinary retention.
The AUA Symptom index score (same as the International Prostate Symptom Score [IPSS]) is an important part of evaluating men with BPH. It is also important in grading the progression of disease or improvement after initiating therapy. The scale is comprised of 7 questions assessing both obstructive and irritative voiding complaints, and each question is graded on a scale of 1 to 5 depending on severity or frequency. IPSS scores of 0 to 7 are classified as mild, 8 to 19 as moderate and 20 to 35 as severe lower urinary tract symptoms (LUTS). Included in the scale is also a bother score graded 1 WATCHFUL WAITING to 5; this allows the patient to rate the impact of the Men with low bothersome scores who don’t have a disease process on their quality of life. Patients with history of urinary tract infections, renal dysfunction, or mild to moderate LUTS and low bother scores should urinary retention are best treated in this manner. The be treated with watchful waiting. Patients with high progression of BPH tends to be slow, and some patients bother scores and/or high AUA index scores should be will actually have an improvement in their IPSS score considered for treatment or further evaluation. over time without intervention. Conservative treatment The PSA and digital rectal exam are also important often includes decreasing fluid intake, eliminating or in the evaluation of men with LUTS. Recently in the limiting caffeine, alcohol, salt and spicy foods. medical literature the PSA has demonstrated a greater PHYTOTHERAPY correlation with BPH. Please keep in mind that you The two most common herbals for prostate health are will frequently encounter patients with low PSA’s and Serenoa repens (Saw Palmetto) and Pygeum africanum severe BPH. The same holds true for men with very (Red stinkwood or African Plum). large prostates and low IPSS scores. There are now A Meta analysis of randomized trials using Saw Palmetto by Boyle et al (2859 patients enrolled) showed an increase of 2.71mls/sec in peak flow rates compared to A recent study compared the gold standard TURP to 0.5ms/sec in the placebo arm. There was also a decrease microwave therapy. The TURP peak urinary flow rates in nocturia by 1.19 events compared to 0.69 for placebo. increased from 9.3ml/s to 19.1ml/s. The TUMT arm An older Meta analysis showed that Saw Palmetto’s improved from a pre-treatment flow rate of 9.3ml/ efficacy approached that of Finasteride (Proscar). s to 15.1 ml/s. Patient’s subjective scores were also The efficacy of Pygeum africanum is being evaluated slightly better for the conventional TURP. Multiple currently in a NIH longitudinal study (complimentary studies have concluded that Microwave therapy is and alternative medicine trial [CAMUS]). No study to a solid option for BPH but is not equivalent to the date with a placebo arm has been performed. conventional TURP. TUMT is an excellent choice for patients when pharmacotherapy has failed or The AUA guideline committee believes that all 4 is contra-indicated, and the risks and morbidity of alpha blockers (Alfuzosin, Doxazosin, Tamsulosin, and Terazosin) are equally effective causing on average a 4 to 6 point improvement in the AUA symptom score. Many clinicians feel the selective alpha-blockers management. The introduction of the laser allows Flomax and Uroxatrol are more effective than the a different energy for achieving the same endpoint. non selective. The rates of retrograde ejaculation are The results of several prospective studies comparing highest with Flomax. Uroxatral has a higher incidence Electrocautery to laser TURP showed similar efficacy. of hypotension in the selective alpha-blocker group. Improvement in symptom score and increased peak The alpha-blockers have a short onset of action but do flow rates were equivalent. Voiding outcomes at 12 little to reduce the incidence of acute urinary retention. months in both modalities were comparable.
Therefore they typically loose there benefit over time in The benefits of the laser TURP over electrocautery is, reduced risk of TUR syndrome, decreased irritative voiding symptoms, less postoperative bleeding Proscar and Avodart are the 2 drugs in this class. They along with fewer electrolyte abnormalities. work best in patients with large prostate glands > 40cc. Electrocautery provides a tissue specimen for These drugs tend to take 3 to 6 months before patients pathology along with a shorter operative time.
see significant improvement in bother score; however their greatest benefit is in reducing the incidence of EMERGING TREATMENTS
Our office is conducting two clinical trials on novel therapies for BPH. One trial involves a one-time The MTOPS study demonstrated combining an alpha injection of medicine directly into the transitional -blocker with a 5 alpha-reductase inhibitor worked zone of the prostate. The other trial involves better than either one alone at reducing not only the a medication taken by mouth that has a new AUA index score but slowing disease progression and mechanism of action that addresses the prostate MICROWAVE THERAPYThe first Microwave therapy (TUMT) was performed in UPCOMING TOPICS
1982 for prostate cancer. In 1985 high-risk BPH patients were treated. Currently TUMT is an option at most stages of BPH. Microwave therapy works by heating 3. Renal, Bladder, Prostate, Testicular Cancer the prostate adenoma while simultaneously cooling There are a number of devices on the market with varying efficacy. I have been fortunate to use four machines and the Prolief system dilates and heats the prostate during treatment and has provided the best results. The procedure takes 45 minutes to 1 hour in the office and requires only local anesthesia. Patients typically bring something to read or music to listen to

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